The levels of evidence supporting the recommendations (I-IV) and clinical practice points (CPP) are defined at the end of the "Major Recommendations" field.
Sensorimotor Impairments
Strength
- One or more of the following interventions should be used for people who have reduced strength: Progressive resistance exercises; (Level II, Morris, Dodd, & Morris, 2004])
- Electromyographic biofeedback in conjunction with conventional therapy; (Level II, [Basmajian et al., 1975; Inglis et al., 1984])
- Electrical stimulation; (Level I, [Glanz et al., 1996]; Level II, [Cauraugh et al., 2000])
- Task-specific training. (Level II, [Duncan et al., 2003; Winstein et al., 2004])
Sensation
One or more of the following interventions for increasing tactile and kinaesthetic sensation may be provided for people who have sensory impairments:
- Sensory-specific training; (Level III-2, [Yekutiel & Guttman, 1993]; Level III-3, [Carey, Matyas, & Oke, 1993; Byl et al., 2003])
- Sensory-related training; (Level III-2, [Carey & Matyas, 2000])
- Cutaneous electrical stimulation in conjunction with conventional therapy. (Level IV, [Peurala et al., 2002])
Spasticity
One or more of the following interventions may be provided for people who have moderate to severe spasticity (i.e., spasticity that interferes with a stroke survivor's activity or personal care):
- Botulinum Toxin A; (Level I, [Van Kuijk et al., 2002])
- Intrathecal baclofen; (Level I, [Creedon, Kijkers, & Hinderer, 1997] Level II, [Meythaler et al., 2001])
- Dynamic splinting; (Level III-2, [Gracies et al., 2000])
- Vibration; (Level II, [Ageranioti et al., 1990])
- Stretch; (Level II, [Carey, 1990] Level III-2, [Nuyens et al., 2002])
- Electromyographic biofeedback. (Level III-2, [Swaan, van Wieringen, & Fokkema, 1974])
Interventions to decrease spasticity should not be routinely provided for people who have mild to moderate spasticity (i.e., spasticity that does not interfere with a stroke survivor's activity or personal care). (CPP)
Contracture
For people at risk of developing contractures, management may include prolonged positioning of muscles in a lengthened position to maintain range of motion. (Level II, [Ada et al., 2005])
Overhead pulley exercise should not be used to maintain range of motion of the shoulder. (Level III-1, [Kumar et al., 1990])
For people who have contractures, management may include the following interventions to increase range of motion:
- Electrical stimulation; (Level III-3, [Pandyan, Granat, & Stott, 1997])
- Casting. (Level I, [Mortenson & Eng, 2003])
Subluxation of the Shoulder
For people with severe weakness who are at risk of developing a subluxed shoulder, management should include either or both of the following interventions to minimise subluxation:
- Electrical stimulation; (Level I, [Ada & Foongchomcheay, 2002])
- Firm support devices. (CPP)
For people who have developed a subluxed shoulder, management may include firm support devices to prevent further subluxation. (Level III-2, [Brooke et al., 1991; Moodie, Brisbin, & Morgan, 1986; Williams, Taffs, & Minuk, 1988; Zorowitz et al., 1995])
Shoulder Pain
For people with severe weakness who are at risk of developing shoulder pain, management should include interventions to educate staff, carers and people with stroke to prevent trauma. (CPP)
Swelling of the Extremities
For people who are immobile, management may include the following interventions to prevent swelling in the hand and foot:
- Electrical stimulation; (Level III-1, [Faghri, 1997])
- Continuous passive motion in elevation; (Level III-2, [Giudice, 1990])
- Pressure garments. (Level III-2, [Gracies et al., 2000])
For people who have swollen extremities, management may include the following interventions to reduce swelling of the hand and foot:
- Electrical stimulation; (Level III-1, [Faghri, 1997])
- Continuous passive motion in elevation. (Level III-2, [Giudice, 1990])
Cardiovascular Fitness
Rehabilitation should include interventions to increase cardiovascular fitness once people have sufficient strength in the large lower limb muscle groups. (Level I, [Van Peppen et al., 2004]; Level II, [Duncan et al., 2003; Chu et al., 2004])
Falling
Multifactorial interventions provided in the community, including an individually prescribed exercise program, may be provided for people who are at risk of falling, in order to prevent or reduce the number and severity of falls. (Level I, [Gillespie et al., 2003])
Physical Activity
Sitting
Supervised task-specific sitting practice should be provided for people who have difficulty sitting. (Level II, [Dean & Shepherd, 1997])
Standing Up from a Chair
Task-specific practice of standing up should be provided for people who have difficulty in standing up from a chair. (Level I, [Van Peppen et al., 2004])
Standing
Task-specific standing practice with feedback may be provided for people who have difficulty standing. (Level I, [Van Peppen et al., 2004; Barclay-Goddard et al., 2004])
Walking
One or more of the following interventions should be provided for people who can walk but with difficulty:
- Joint position biofeedback with or without conventional therapy; (Level II, [Morris et al., 1992]; Level III-2, [Ceceli, Dursun, & Cakci, 1996])
- Cueing of cadence; (Level I, [Van Peppen et al., 2004])
- Treadmill with or without body weight support; (Level I, [Van Peppen et al., 2004; Moseley et al, 2003])
- Multichannel electrical stimulation in conjunction with conventional therapy; (Level II, [Bogataj et al., 1995]; Level III-2, [Malezic et al., 1987])
- Task-specific training. (Level II, [Duncan et al., 2003; Dean, Richards, & Malouin, 2000; Salbach et al., 2004])
Ankle-foot orthoses may be considered for people with persistent foot drop. If used it should be individually fitted. (Level III-2, [Leung & Moseley, 2003])
Upper Limb Activity
One or more of the following interventions should be provided for people with difficulty using their upper limb:
- Task-specific training; (Level II, [Winstein et al., 2004; Nelson et al., 1996])
- Joint position biofeedback in conjunction with conventional therapy; (Level III-2, [Maulucci & Eckhouse, 2001])
- Robot-assisted reaching; (Level II, [Lum et al., 2002; Volpe et al., 2000])
- Constraint-induced movement therapy. (Level I, [Van Peppen et al., 2004])
Amount of Practice
Rehabilitation should be structured to provide as much practice as possible within the first six months after stroke. (Level I, [Kwakkel et al., 2004])
Group therapy involving task-specific training or video self-modelling may be used to increase the amount of practice in rehabilitation. (Level II, [Dean, Richards, & Malouin, 2000; McClellan & Ada, 2004]; Level III-3, [Eng et al., 2003])
Activities of Daily Living (ADL)
People who have difficulty in ADL should receive occupational therapy or multidisciplinary interventions targeting ADL. (Level I, [Outpatient Service Trialists, 2002; Legg & Drummond, 2001; Walker et al., 2004])
Until clinical safety is proven, administration of amphetamines to improve ADL is not recommended. (Level I, [Martinsson, Wahlgren, & Hardemark, 2003])
Cognitive Capacities
Attention and Concentration
Cognitive therapy may be used in rehabilitation of attention and concentration deficits. (Level I, [Lincoln, Majid, & Weyman, 2000])
Memory
External cues may be used to help prompt memory in people with memory difficulties. (Level II, [Wilson et al., 2001])
Executive Functions
External cues, such as a pager, may be used to initiate everyday activities in people with impaired executive functioning. (Level II, [Wilson et al., 2001])
Visuospatial/Perceptual Capacities
Visual Function
Prism glasses may be used to improve visual function in people with homonymous hemianopia but there is no evidence of benefit in ADL function. (Level II, [Rossi, Kheyfets, & Reding, 1990])
Computer-based visual restitution training may be used to improve visual function in people with visual field deficits. (Level II, [Kasten et al., 1998])
Agnosia
There is insufficient evidence to guide recommendations regarding interventions for agnosia.
Neglect
People with unilateral spatial neglect may benefit from cognitive rehabilitation (for example, scanning training). (Level I, [Bowen, Lincoln, & Dewey, 2002])
Apraxia
Strategy training in conjunction with conventional therapy to improve ADL may help people with apraxia in the short term (<5 months) to improve planning and task execution. (Level II, [Donkervoort et al., 2001])
Communication
Aphasia
Interventions for people with aphasia may include:
- Treatment of phonological and semantic deficits following models derived from cognitive neuropsychology; (Level II, [Doesborgh et al., 2004])
- Constraint-induced therapy; (Level II, [Pulvermuller et al., 2001])
- The use of gesture. (CPP)
The following techniques may be used to enhance therapy for people with aphasia:
- Use of volunteers (including family or staff) trained in supported conversation techniques; (Level II, [Kagan et al., 2001])
- Computer-based therapy programs. (Level II, [Katz & Wertz, 1997])
People with aphasia may be considered for group therapy. (Level II, [Elman & Bernstein-Ellis, 1999])
Until clinical safety is proven and any benefits clearly outweigh any harms, the routine use of the following interventions for aphasia are not recommended:
- Piracetam; (Level I, [Greener, Enderby, & Whurr, 2001])
- Other pharmacological interventions. (CPP)
Aphasia therapy should be commenced as early as possible following a stroke. (CPP)
People with aphasia may benefit from intensive intervention by a speech pathologist. (CPP)
People with severe aphasia may benefit from augmentative and alternative communication devices used in functional activities. (CPP)
Dyspraxia of Speech
Interventions for the treatment of dyspraxia of speech may include modelling, visual cueing, integral stimulation and articulatory placement cueing. (Level IV, [Wambaugh et al., 1998])
People with severe apraxia of speech may benefit from augmentative and alternative communication devices used in functional activities. (CPP)
Dysarthria
Interventions for the treatment of dysarthria may include:
- Biofeedback or a voice amplifier to change intensity and increase loudness; (Level IV, [Simpson, Till, & Goff, 1988])
- A palatal lift to compensate for velopharyngeal incompetency; (Level IV, [Bedwinek & O'Brien, 1985; Kerman, Singer, & Davidoff, 1973; Yorkston et al., 1989])
- The use of strategies such as decreased rate, overarticulation or gesture; (CPP)
- Oral musculature exercises. (CPP)
People with severe dysarthria may benefit from augmentative and alternative communication devices used in functional activities. (CPP)
Dysphagia
Compensatory strategies such as positioning, therapeutic manoeuvres or modification of food and fluids to facilitate safe swallowing may be provided for people with dysphagia. (Level IV, [Elmstahl et al., 1999])
One or more of the following methods may be provided to facilitate resolution of dysphagia:
- "Shaker" therapy targeting specific muscle groups; (Level II, [Shaker et al., 2002])
- Thermo-tactile stimulation; (Level II, [Rosenbek et al., 1998])
- Electrical stimulation. (Level III-3, [Freed et al., 2001])
Hydration and Nutrition
Fluid supplementation by appropriate methods should used to treat or prevent dehydration. (Level I, [Whelan, 2001; Simmons, Alessi, & Schnelle, 2001; Hodgkinson, Evans, & Wood, 2003])
Nutritional supplementation should be offered to people whose nutritional status is poor or deteriorating. (Level I, [Milne, Potter, & Avenelle, 2002])
Early enteral tube feeding via a nasogastric (NG) tube may be used for people who require alternative feeding methods as a consequence of dysphagia. (Level II, [Dennis et al., 2005])
NG rather than percutaneous endoscopic gastrostomy (PEG) feeding should be used routinely during the first month post-stroke for people who do not recover a functional swallow. (Level II, [Dennis et al., 2005])
Decisions regarding long-term enteral feeding for people who do not recover a functional swallow should be made in consultation with the person with stroke and the family. (CPP)
If a decision is taken for long-term enteral feeding, a PEG or similar permanent feeding tube should be used. (CPP)
People with stroke should be monitored to prevent dehydration. (CPP)
People who are at risk of malnutrition, including those with dysphagia, should be referred to a dietitian for assessment and management. (CPP)
Mood
Routine use of pharmacological therapy to prevent post-stroke depression is not currently recommended. (Level I, [Anderson, Hackett, & House, 2004])
Psychological interventions may be provided to improve mood for people without depression however it is unclear if such interventions prevent depression. (Level II, [Anderson, Hackett, & House, 2004])
Antidepressants and/or psychological interventions may be provided for people with depression or emotional lability. (Level I, [House et al., 2004; Hackett, Anderson, & House, 2004])
Cognitive behaviour therapy and/or antidepressants may be used for people with anxiety disorders. (CPP)
ECT may be considered in major, drug-resistant depression following stroke. (CPP)
Continence
Bladder Function
All people with urinary dysfunction should be managed using an organised, functional approach to rehabilitation. (Level II, [Wikander, Ekelund, & Milsom, 1998])
For people with urinary retention:
- The routine use of indwelling catheters is not recommended. However if urinary retention is severe, then intermittent catheterisation should be used to assist bladder emptying. (CPP)
- If using intermittent catheterisation, then a closed catheterisation technique should be used. (Level II, [Quigley & Riggin, 1993])
For people with urge incontinence:
- A prompted or scheduled voiding regime program, bladder retraining and anticholinergic drugs should be considered. (CPP)
- If continence is unachievable, containment aids may assist with social continence. (CPP)
For people with functional incontinence, a whole-team approach is recommended. (CPP)
If incontinence persists then further tests should be undertaken. (CPP)
Bowel Function
For those with bowel dysfunction, an appropriate assessment (including a rectal examination) and targeted education should be provided. (Level II, [Harari et al., 2004])
Bowel training may be used for people who have bowel dysfunction. (Level III-3, [Venn et al., 1992; Munchiando & Kendall, 1993])
If continence is unachievable, containment aids may assist with social continence. (CPP)
Medical
Pain
Amitriptyline should be preferred over carbamazepine, however either may be considered when treating people with central post-stroke pain (CPSP). (Level II, [Leijon & Boivie, 1989])
Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)
Antiplatelet therapy should be used for people with ischaemic stroke to prevent DVT/PE. (Level I, ["Collaborative overview," 1994])
The following interventions may be used with caution (taking into account the risks and benefits) for selected people at high risk of DVT/PE (i.e., history of DVT/PE, morbid obesity or known prothrombotic tendency):
- Heparin or low molecular weight heparin in prophylactic doses; (Level I, [Bath, Iddendan, & Bath, 2000; Counsell & Sandercock, 2001]; Level II, [" The International Stroke Trial (IST)," 1997])
- Thigh-length antithrombotic stockings. (Level I, [Amaragiri & Lees, 2000; Mazzone et al., 2004])
Pyrexia
People with fever should be investigated to identify the source (e.g., infection of urinary tract, respiratory tract, skin, intravenous site). (CPP)
Antipyretic therapy, comprising regular paracetamol and/or physical cooling measures, should be used routinely where fever occurs. (CPP)
Seizures
Anti-convulsant medication may be used for people with recurrent seizures. (Level I, [Marson et al., 2000; Tudur Smith et al., 2002; Tudur Smith, Marson, & Williamson, 2003])
Sleep Apnoea
For people with sleep apnoea after stroke:
- Continuous positive airway pressure (CPAP) should be considered as the first line treatment. (Level I, [White, Cates, & Wright, 2001]; Level II, [Wessendorf et al., 2001; Sandberg et al., 2001])
- If the person is unable or unwilling to use CPAP, then oral appliances or postural therapy may be considered. (CPP)
Secondary Prevention
Antiplatelet Therapy
Antiplatelet therapy in the form of aspirin, or clopidogrel, or a combination of low dose aspirin and modified release dipyridamole, should be prescribed to all people with ischaemic stroke who are not prescribed anticoagulation therapy. (Level I, [Antithrombotic Trialists Collaboration, 2002])
Anticoagulation
Anticoagulation therapy for long-term secondary prevention should be used in all people with ischaemic stroke or transient ischemic attack (TIA) who have documented atrial fibrillation, cardioembolic stroke from valvular heart disease, or recent myocardial infarction, unless a contraindication exists. (Level I, [Gubitz, Sandercock, & Counsell, 2004; Sandercock et al., 2002])
Anticoagulation should not be started for 7-14 days after a disabling ischaemic stroke, to minimise the risk of cerebral haemorrhage. (CPP)
Blood Pressure Lowering Therapy
All people after stroke or TIA, whether normotensive or hypertensive, should receive blood pressure lowering advice or drug therapy, unless contraindicated by symptomatic hypotension. (Level I, [Rashid, Leonardi-Bee, & Bath, 2003])
Commencement of new blood pressure lowering therapy should generally be delayed until the person with stroke is clinically stable. (CPP)
Cholesterol
Therapy with a statin should be considered for people with a total cholesterol level >3.5 mmol/L following ischaemic stroke. (Level II, Collins et al., 2004])
People with high cholesterol levels should be considered for dietetic referral for nutritional review and counselling. (CPP)
Behaviour Change
Every person with stroke should be assessed and informed of their risk factors for a further stroke and possible strategies to modify identified risk factors. The risk factors and interventions include:
- Smoking cessation: nicotine replacement therapy and behavioural therapy should be used; (Level I, [Lancaster & Stead, 2002; Silagy et al., 2004; Rice & Stead, 2004; Rigotti et al., 2002])
- Improved diet: a diet that is low in fat (especially saturated fat) and sodium, but high in fruit and vegetables should be consumed. Potassium supplements may be used; (Level I, [Hooper et al., 2001; He & MacGregor, 2004; Hooper et al., 2004; Mulrow et al, 1998; Cappucio & MacGregor, 1991]; Level II, [Jula et al., 2002; Sdringola et al., 2003; Appel et al., 1997; de Lorgeril et al., 1999; Sacks et al., 2001; Barzi et al., 2003])
- Increase regular exercise; (CPP)
- Avoidance of excessive alcohol. (CPP)
Interventions should be individualised and may be delivered using behavioural techniques (e.g., counselling) via a group or on a one-to-one basis. (Level I, [Lancaster & Stead, 2002; Rice & Stead, 2004; Stead & Lancaster, 2002])
Concordance with Medication
Interventions to promote adherence to medication regimes are often complex and may include one or more of the following:
- Information, reminders, self-monitoring, reinforcement, counselling, family therapy; (Level I, [Haynes et al., 2002; Schedlbauer et al., 2004])
- Reduction in the number of daily doses; (Level I, [Haynes et al., 2002; Schroeder, Fahey, & Ebrahim, 2004])
- Multi-compartment medication compliance device; (CPP)
- Specific aids to counter stroke-related deficits (physical or cognitive). (CPP)
Complementary Medicine and Alternative Therapies
Until clinical safety is proven and any benefits clearly outweigh harms, the routine use of the following complementary and alternative therapies are not recommended in stroke rehabilitation:
- Acupuncture; (Level I, [Park et al., 2001; Sze et al., 2002])
- Reiki therapy; (Level II, [Shiflett et al., 2002])
- Other alternative therapies. (CPP)
Health professionals should be aware of different forms of complementary and alternative therapies and be available to discuss these with stroke survivors and their families. (CPP)
Palliation and Death
Health professionals who are trained in communication associated with palliative care should be involved in the care of people with stroke who are dying and with their families. (CPP)
People with stroke who are dying, and their families, should have care that is consistent with the principles and philosophies of palliative care. (CPP)
Definitions:
Levels of Evidence
| I |
Evidence obtained from a systematic review of all relevant randomised controlled trials. |
| II |
Evidence obtained from at least one properly designed randomised controlled trial. |
| III-1 |
Evidence obtained from well-designed pseudo-randomised controlled trials (alternate allocation or some other method). |
| III-2 |
Evidence obtained from comparative studies with concurrent controls and allocation randomised (cohort studies), case-control studies, or interrupted time-series with group. |
| III-3 |
Evidence obtained from comparative studies with historical control, two or more studies, or interrupted time series without a parallel control group. |
| IV |
Evidence obtained from case series, either post-test or pre-test and post-test. |
Clinical Practice Points
| CPP |
Recommended best practise based on clinical experience and expert opinion. |
